Luby S, Carmichael S, Shaw G, Horan J, Gamble W, Jones J
Division of Field Epidemiology, Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA 30333.
J Fam Pract. 1994 Jul;39(1):21-5.
The national incidence of tuberculosis (TB) is increasing, and hospitals are a site of transmission. We investigated a nosocomial outbreak of TB at a 160-bed community hospital in South Carolina that highlights the central role that primary care physicians must play to control this epidemic.
We reviewed medical records to identify potential source cases. We retrospectively evaluated exposures to suspected source patients and the subsequent tuberculin reactivity of the 38 hospital employees who had a previous negative tuberculin skin test and were assigned to the ward where the outbreak began. We also evaluated the out-of-hospital contacts of TB cases.
A review of medical records identified one patient who had died of prostate cancer and chronic cavitary pneumonia but was never in isolation nor evaluated for TB. Ward employees who worked while this patient was hospitalized had an increased risk for skin-test conversion (43% [12 of 28] vs 0% [0 of 9]; relative risk undefined; P = .02). Among employees who worked with this patient, skin-test converters worked more shifts with (median, 10.5 vs 7), dispensed more medication to (median 7 doses vs 1), and wrote more notes on (median 18 vs 5) the index patient than did nonconverters. Five of 12 of the patient's close out-of-hospital contacts had newly recognized positive tuberculin skin tests. Among 20 casual contacts, there were no new skin-test conversions.
A high index of suspicion, prompt isolation and diagnostic testing of potentially infectious hospitalized patients, and a thorough investigation of contacts of patients with TB are needed to prevent TB transmission.
全国结核病发病率呈上升趋势，医院是结核病传播场所。我们对南卡罗来纳州一家拥有160张床位的社区医院内发生的一起医院内结核病暴发进行了调查，该调查突出了初级保健医生在控制这一流行病中必须发挥的核心作用。
我们查阅病历以确定潜在的源头病例。我们回顾性评估了38名医院员工对疑似源头患者的暴露情况以及随后的结核菌素反应性，这些员工之前结核菌素皮肤试验呈阴性，且被分配到暴发起始的病房工作。我们还评估了结核病病例的院外接触者。
病历审查发现一名死于前列腺癌和慢性空洞性肺炎的患者，但该患者从未被隔离，也未接受结核病评估。在该患者住院期间工作的病房员工皮肤试验阳转风险增加（43%[28人中的12人]对0%[9人中的0人]；相对风险未定义；P = 0.02）。在与该患者共事的员工中，皮肤试验阳转者与该索引患者的班次更多（中位数分别为10.5和7），给该患者分发的药物更多（中位数分别为7剂和1剂），为该患者书写的病历记录更多（中位数分别为18份和5份）。该患者的12名院外密切接触者中有5人结核菌素皮肤试验新转为阳性。在20名偶然接触者中，无新的皮肤试验阳转情况。
需要高度的怀疑指数、对潜在感染性住院患者的及时隔离和诊断检测，以及对结核病患者接触者的彻底调查，以预防结核病传播。
